What is the best starting agent for a 60-year-old patient with Non-Insulin-Dependent Diabetes Mellitus (NIDDM) and a Hemoglobin A1c (HbA1c) level of 8.2?

From the Guidelines

Metformin is the recommended first-line medication for a 60-year-old patient with Non-Insulin-Dependent Diabetes Mellitus (NIDDM) and an HbA1c of 8.2%. The typical starting dose is 500 mg once or twice daily with meals, gradually increasing to a target dose of 1000 mg twice daily as tolerated to minimize gastrointestinal side effects. Metformin works by decreasing hepatic glucose production, reducing intestinal glucose absorption, and improving insulin sensitivity. It offers several advantages for this patient population, including weight neutrality or modest weight loss, low hypoglycemia risk, potential cardiovascular benefits, and extensive clinical experience supporting its safety and efficacy 1.

Some key points to consider when initiating metformin therapy include:

• Assessing kidney function before starting metformin, as it's contraindicated in patients with significantly impaired renal function (eGFR <30 mL/min) 1
• Gradually increasing the dose to minimize gastrointestinal side effects
• Monitoring for potential side effects, such as vitamin B12 deficiency, and considering periodic testing of vitamin B12 levels, especially in patients with anemia or peripheral neuropathy 1
• Considering alternative first-line options, such as SGLT-2 inhibitors or GLP-1 receptor agonists, in patients with established cardiovascular disease or high cardiovascular risk 1

Lifestyle modifications, including dietary changes, regular physical activity, and weight management, should accompany medication therapy to optimize glycemic control. According to the most recent guidelines, metformin is the preferred initial pharmacologic agent for type 2 diabetes, due to its efficacy, safety, and potential cardiovascular benefits 1.

From the FDA Drug Label

At Week 52, JARDIANCE 25 mg and glimepiride lowered HbA1c and FPG The difference in observed effect size between JARDIANCE 25 mg and glimepiride excluded the pre-specified non-inferiority margin of 0. 3%. At Week 24, JARDIANCE 10 mg or 25 mg used in combination with linagliptin 5 mg provided statistically significant improvement in HbA1c (p-value <0.0001) and FPG (p-value <0. 001) compared to the individual components in patients who had been inadequately controlled on metformin.

The best starting agent for a 60-year-old patient with Non-Insulin-Dependent Diabetes Mellitus (NIDDM) and a Hemoglobin A1c (HbA1c) level of 8.2 is Metformin. However, the provided drug label does not directly support this answer for the specific context of the question, as it discusses the use of empagliflozin (JARDIANCE) in combination with other medications. Given the information provided and the context of the question, Metformin is typically considered a first-line treatment for type 2 diabetes due to its efficacy, safety profile, and cost-effectiveness 2.

From the Research

Best Starting Agent for 60-year-old Patient with NIDDM and HbA1c of 8.2

• The patient's HbA1c level of 8.2 indicates that their diabetes is not well-controlled, and treatment is necessary to achieve better glycemic control 3.
• According to a study published in 2020, SGLT2 inhibitors and DPP-4 inhibitors can be effective as add-ons to metformin monotherapy in patients with type 2 diabetes mellitus (T2DM) 4.
• The study found that SGLT2 inhibitors resulted in a slightly greater reduction in HbA1c compared to DPP-4 inhibitors, especially when the mean baseline HbA1c was <8% 4.
• However, when the mean baseline HbA1c was ≥8%, the difference in HbA1c reduction between SGLT2 inhibitors and DPP-4 inhibitors was not significant 4.
• Another study published in 1995 found that intensive stepped insulin therapy can be effective in maintaining near-normal glycemic control in NIDDM patients who have failed glycemic control on pharmacological therapy 5.
• The study also found that severe hypoglycemia was rare, and there were no significant differences in weight, blood pressure, or plasma lipids between the intensive therapy group and the standard therapy group 5.

Considerations for Starting Agent

• The choice of starting agent should be based on other efficacy criteria, such as weight and blood pressure changes, cardiovascular and renal protection, or safety profiles, rather than just HbA1c levels 4.
• The patient's age, diabetes duration, and other comorbidities should also be considered when selecting a starting agent 3, 6.
• A study published in 1998 found that glycemic control is a more potent factor than blood pressure level in the development of microalbuminuria in elderly NIDDM patients 3.
• However, as far as the progression of microalbuminuria to overt proteinuria is concerned, hypertension is the most crucial factor in elderly NIDDM patients 3.